9 year-old boy, images received from an outside hospital after a longstanding nasopharygeal viral infection. Spiking fevers up to 40° C have been reported. Now, after a fall, the patient is dazed. The patient underwent a CT with the concern for cerebral hemorrhage. Only mild leucocytosis.

CT 1: slight frontal edema bilaterally. Result of trauma? Infection? After 5 days, the child was transferred to the children's hospital because of progressing impairment of consiousness.

Pathomorphology or Pathophysiology of this disease :

Proof of pathogen in the abscesses: Staphylococcus.

The etiology of bacterial cerebral abscesses can be hematogenic (often endocarditis), after trauma or can be due to direct extension from a neighbouring infectious process. A common cause is sinusitis with a concurring bony defect in the posterior wall of the frontal sinus (as in this case). In immune-competent patients, fungal pathogens should also be considered besides a bacterial infection.

MRI 2: T1-weighted after contrast administration directly after admission: Subdural and epidural fluid capsule with intense wall enhancement frontoparietal as well as temporal and basal.

MRI 3: No MRI, rather a supplemental CT: Left upper corner: Single slice in bone window. Right lower corner: 3D reconstruction in the area of the frontal sinuses: Defect in the right, posterior frontal sinus wall.

MRI 4: T1-weighted, after contrast administration: Treatment of the frontal sinuses in the ENT unit, neurosurgical trepanation on the right side. The intraparenchymal changes do not show any change (increase of the focal edema, on T1-weighted images signal focal signal loss)

MRI 5: T1-weighted, after contrast administration: After 2 months of conservative treatment and without further surgical intervention (hyperbaric oxygenation, antibiotics), further decrease of the frontal intracerebral lesions. Only small enhancing rests left with minimal surrounding residual edema.

Diagnosis confirmation:

Surgery / Histo

Which DD would be also possible with the radiological findings:

Glioblastoma, in a purely intracerebral location also pilocytotic astrocytoma

Course / Prognosis / Frequency / Other :

Clinically it often starts subtle. Commonly, there is only a moderate leucocytosis. In chronic courses and a thick abscess membrane, it might be mistaken with a glioblastoma multiforme is possible, since both changes commonly show a perifocal edema.